Succinylcholine is a commonly used depolarizing muscle relaxant in general endotracheal anesthesia. The degradation of succinylcholine is accomplished by the human serum based enzyme pseudocholinesterase. Availability of pseudocholinesterase within the human being can be deficient as a result of an inherited or acquired cause. This case report will describe a female patient who was diagnosed with an acquired pseudocholinesterase deficiency.
Rates of obesity are rising throughout the world. Obese patients have a number of co-morbidities and associated diseases which can impact the safe transportation of these patients. This overview of the retrieval of bariatric or obese patients will explain some of the physiological and different co-morbidities found in these patients, as well as some more practical advice when faced with transporting these patients.
Bariatric or weight loss surgery is the only treatment for morbid obesity that confers definitive weight loss at long-term follow-up. In addition to weight reduction there is a strong possibility of amelioration or even cure of various co-morbid conditions associated with obesity such as Type II diabetes mellitus, obstructive sleep apnoea, hypertension, asthma, osteoarthritis and gastro-oesophageal reflux disease.
This is a case report of a patient with Crohn's disease admitted to hospital with a typical flare. The main symptoms were abdominal pain and haemorrhagic diarrhoea. During the current admission she was commenced on her first course of Infliximab.
In this review article Bunker et al. present their approach to the clinical conundrum regarding the use of red cell transfusion triggers. The impetus to use numerical values of haemoglobin concentration as transfusion triggers has been driven by several factors that have been clearly outlined by the authors. Whilst public perception may differ, blood itself has never been safer and currently the most pressing problem associated with this pharmacological product is the reduction in the donor pool and the exponential rise in cost due to even more sensitive screening tools and pathogen inactivation methods. This has to be tempered with the fact that decisions at the bedside will depend ultimately on the rapidity of blood loss that leads to anaemia and the co morbidities of the patient that may affect their compensatory reflexes such as ischaemic heart disease. As highlighted, the compensatory mechanisms to acute anaemia aim to preserve global oxygen delivery and involve an increase in cardiac output and an increased oxygen extraction ratio. Clearly there will be considerable variation between individuals dependant upon co-morbidities. At the bedside this translates to ‘how low is safe’ when delineating the limits of haemodilution and the concept of the ‘critical point’ emerges. This is the haemoglobin threshold at which compensatory mechanisms are overwhelmed and the sacrosanct oxygen delivery becomes inadequate to meet the oxygen demands of the individual. At present there is no way of knowing this value for an individual and therefore making clinical decisions in advance to allow a reasonable margin of safety. What is more common is the scenario that exists when the ‘critical point’ has been passed when markers of tissue hypoperfusion such as metabolic acidosis and increased lactate occur. The problem is however, that these markers are not specifically related to the requirement for a transfusion. The anxiety related to the adoption of low transfusion triggers in the latter group revolve around the provocation of coronary ischaemia be that overt or covert silent myocardial ischaemia. This is related to the high oxygen extraction ratio of the myocardium which therefore little capacity to increase this further in response to reduced arterial oxygen content. Figs. 1 and 2 serve to highlight the complex interrelationship between haemoglobin concentration, its fall, the concomitant rise in cardiac output to compensate for drop in haemoglobin and the ‘critical point’. A more pertinent point is that the ‘critical point’ is reached
Stroke due to intracerebral hemorrhage is a recognized life threatening but rare complication of eclampsia and severe pre-eclampsia. Literature reporting the anesthetic management of combined emergency cesarean section and craniotomy are scarce. We describe the anesthetic management of a 21-year-old primigravida who underwent combined emergency cesarean section and craniotomy for intracerebral hemorrhage secondary to severe pre-eclampsia. Management of a pregnant woman with an intracerebral bleed and the emergency situation is an anesthetic challenge. A combined procedure as above requires good communication and co-ordination between various specialities and attention to details to ensure successful maternal and neonatal outcome.
The mechanical ventilation of neonates and children in operating theatres has always posed a challenge for anaesthesiologists. Firstly, the extreme physiological features of neonatal lungs make them very difficult to ventilate with an anaesthesia ventilator. Gattinoni’s “baby lung” concept to describe ARDS lungs in adults comes from the physiological features of neonatal lungs (low dynamic compliance, low pulmonary time constant, low FRC, high closing volume, proneness to atelectasis, high inspiratory airway resistance). Secondly, the performance and technology (peak flow, insufflation power, trigger sensitivity, ventilation modes, etc.) of anaesthesia ventilators is still less advanced than those of critical care ventilators. It is possible to ventilate a normal healthy adult lung with an anaesthesia ventilator, but even today, using circle circuits, ventilating a premature baby, newborn or child in the operating theatre can be a real challenge. Over the last 5 years, great changes have been made to anaesthesia workstations, which now boast better mechanical ventilation performance for children as well as new ventilation modes. However, there is a lack of background knowledge regarding mechanical ventilation in operating theatres, and this limits the advantages that can be derived from this new technology, and thus any potential safety improvements in paediatric surgery.
Local anaesthetic toxicity has been a known complication of local anaesthetics since use began in 1884 and it continues to be a problem in modern medical practice.
The prevalence of morbid obesity in the United Kingdom is increasing at an exponential rate. The field of bariatric surgery has expanded accordingly over the past decade. Obesity related co-morbidity increases the risk of perioperative complications, and morbidly obese patients presenting for bariatric surgery pose particular challenges to the anaesthetist. This article addresses key issues relevant to pre-operative assessment, and anaesthetic management of morbidly obese patients presenting for bariatric surgery.
Postoperative pulmonary dysfunction (PPD) is a frequent complication after cardiac surgery. Its pathogenesis is related to pulmonary inflammation, but this appears to be secondary to multiple etiological factors, including the surgical procedure itself, extra corporeal circulation (ECC), ischemia-reperfusion injury, and mechanical ventilation (MV). On the other hand, the presence of atelectasis remains one of the principal causes of PPD. The open lung approach (OLA) is a protective ventilation strategy, typically initiated after orotracheal intubation and maintained until extubation of the patient. Compared to a conventional ventilation strategy, OLA improves gas exchange parameters, induces a minor elevation of inflammatory mediators, and retains more residual functional capacity. Finally, recent studies have shown that the addition of low frequency ventilation during ECC can decrease the incidence of PPD after cardiac surgery.
Nasogastric gastric tubes (NGT) are placed blindly at the bedside in critical care although the procedure is associated with occasional serious pleuro-pulmonary complications. Various factors have been reported to predispose to the feeding tube malposition. We report a 60-year male in whom the attempted NGT insertion led to a near fatal complication. He was admitted to the medical intensive care-unit of our institute with dysphagia, cough with expectoration and breathlessness. In an un-cooperative patient with ineffective cough, the administration of sedation and multiple attempts to place the NGT resulted in an impacted tooth in the upper esophagus, and misplacement of the NGT. An urgent chest radiograph showed that the NGT had entered into the airway and its tip lay in the left main bronchus. A brief review of the complications associated with NGT insertion is presented.
Mechanical ventilation is a fundamental tool in the clinical daily management of anesthetic procedures and it constitutes a cornerstone in the final evolution of the critical patients. Historically, Volume-controlled ventilation (VCV) has been the universal ventilatory mode used by the anesthesiologists in operating theatre. Nevertheless, since Pressure-controlled ventilation (PCV) was proposed as an alternative to VCV in ICU patients with ALI/ARDS, there has been renewed interest in ventilatory pressure modes in anesthesia. At present the anesthesia workstations usually have available some different modes such as PCV or pressure support ventilation (PSV). The purpose of this review is to evaluate whether ventilatory pressure modes, such as the PCV offer some benefit over the classic VCV, during anesthesia for different types of patients and surgery.
Reliable and valid measures of risk and outcome are essential prerequisites for the effective monitoring of outcome following surgery and the evaluation of innovations in perioperative care. Enhanced Recovery (ER) programs raise the exciting prospect of reduced resource utilisation in combination with improved (or at least equivalent) outcomes. Careful monitoring of process (compliance with ER elements) and outcome are essential if this goal is to be achieved without unintended harm to patients (e.g. increased readmission due to postoperative morbidity arising in the community).
The induction of transplantation tolerance has become a major goal, because modern immunosuppressive therapy has not improved chronic rejection rates, and is associated with significant side effects. This article aims to explain the principles of immunological tolerance. Mechanisms of central tolerance involve deletion of self-reactive T cells. Mechanisms of peripheral tolerance are reviewed and also the identification of a subset of regulatory T cells which are characterised by the expression of the transcription factor FoxP3.
Airway management is often the principal concern of the majority of anaesthetists when presented with an obese patient for general anaesthesia. Many anaesthetists will be increasingly encountering obese patients requiring all types of surgery. With the expansion of bariatric surgery both worldwide and in the UK, there is now a greater evidence base to inform and guide airway management in the obese patient. This article aims to improve understanding of the term ‘difficult airway’ in the obese population and focuses primarily on evidence related to pre-operative airway assessment and intra-operative airway management in the obese patient.
